Barriers and Facilitators for TB Control in Urban India and Recommendations for an Effective ...

43 Pages·2014·0.81 MB·English

Barriers and Facilitators for Early TB Detection and Completion of Treatment in Urban India

Barriers and Facilitators for TB Control in
Urban India and Recommendations
for an Effective ACSM Strategy
– A Review

by
Population Services International/India (PSI)
on behalf of
Improving Healthy Behaviors Program (IHBP)

and
United States Agency for International Development
(USAID)

February 2013

This publication is made possible by the generous support of the American people through the U.S. Agency for
International Development (USAID) under the terms of Contract No. AID-386-TO-11-00001. The content is the sole
responsibility of IHBP, managed by FHI 360, a North Carolina, U.S.-based global nonprofit organization, and does
not necessarily reflect the views of USAID or the United States Government.
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Barriers and Facilitators for Early TB Detection and Completion of Treatment in Urban India

Editorial team:
Dr Nayanjeet Chaudhury, Research Director, PSI ([email protected])
Shri Kaliprosad Roy, National Research Manager, PSI ([email protected])
Dr Puspita Dutta, Assistant Research Manager, PSI ([email protected])
Dr Lakshmi Kota, Research Consultant, PSI ([email protected])
Dr Santosh Kumar Kaza, Research Assistant, PSI ([email protected])

Disclaimer
The comments and discussions presented in this review are those of the editorial team and do not
necessarily reflect the opinion of PSI, IHBP, or USAID.
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Barriers and Facilitators for Early TB Detection and Completion of Treatment in Urban India
Acknowledgement
Population Services International (PSI) sincerely thanks the Improving Healthy Behaviors
Program (IHBP) as well as the United States Agency for International Development (USAID)
for the opportunity to conduct this desk review. The review aims to improve understanding of
the tuberculosis (TB) scenario in urban India and highlight evidence-based recommendations for
an effective advocacy, communication, and social mobilization (ACSM) strategy for urban TB
control.
The authors would especially like to thank the IHBP team — Rita Leavell, Sumit Asthana,
Subrato Mondal, Lopamudra Paul, Pushpraj Dalal, and Amit Paliwal. It would not have been
possible to bring the report to its current form without their valuable suggestions and comments.
We also express our gratitude to PSI’s senior leadership, particularly Sanjeev Dham, Senior
Program Director, for his much cherished guidance and support.
Our special gratitude is due to Dr Venkat Raman from the Faculty of Management Studies,
University of Delhi, for his valuable inputs on the situation of TB care in India.
Last but not the least, we thank each member of the editorial team for their hard work in bringing
out this report.

IHBP is part of the Health Partnership Program Agreement (HPPA) between
USAID and the Government of India. The project collaborates closely with the
Ministry of Health and Family Welfare (MOHFW), the Ministry of Women and
Child Development (MWCD), and their agencies and counterparts at state and
district levels. IHBP focuses on behavior change in four program areas: family planning/reproductive
health, TB, HIV/AIDS, and maternal and child health.

Population Services International (PSI) delivers reproductive and other health products,
services, and information to enable low-income, vulnerable people to change their
behaviors and lead healthier lives. PSI-India, a registered society, began operations in
India in 1988. It focuses on improving consumer access to health products, services, and
information in 22 states and union territories. PSI programs comprise a full menu of targeted marketing
activities in reproductive and child health and prevention of HIV/AIDS, TB, and malaria.
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Barriers and Facilitators for Early TB Detection and Completion of Treatment in Urban India
TABLE OF CONTENTS
ABBREVIATIONS ................................................................................................................................................. 4
EXECUTIVE SUMMARY .................................................................................................................................... 6
1. INTRODUCTION AND OBJECTIVES .................................................................................................... 8
2. METHODOLOGY ....................................................................................................................................... 10
3. BARRIERS TO TB DIAGNOSIS AND TREATMENT ..................................................................... 11
3.1 BARRIERS TO EARLY DIAGNOSIS OF TB .............................................................................................................. 11
3.1.1 AWARENESS AND CORRECT KNOWLEDGE ABOUT TB SYMPTOMS AND CAUSES - PERSPECTIVE OF
GENERAL POPULATION AND PATIENTS .............................................................................................................................. 11
3.1.2 BARRIERS TO EARLY DIAGNOSIS OF TB - PROVIDERS’ PERSPECTIVE ............................................................. 14
3.2 BARRIERS TO TREATMENT AND COMPLIANCE TO TB TREATMENT .............................................................. 16
3.2.1 DEMAND-SIDE DELAY IN SEEKING CARE – PATIENTS’ PERSPECTIVE ............................................................. 16
3.2.2 SUPPLY-SIDE DELAY IN DIAGNOSIS AND TREATMENT INITIATION – PROVIDERS’ PERSPECTIVE ............... 18
3.2.3 DISCONTINUATION OF TREATMENT – PATIENTS’ PERSPECTIVE ................................................................... 20
3.2.4 DISCONTINUATION OF TREATMENT – PROVIDERS’ PERSPECTIVE ................................................................. 21
4. PREVENTION AND CONTROL OF TB IN URBAN INDIA: POSSIBILITIES ....................... 22
5. BUILDING EVIDENCE FROM TRIED AND TESTED INTERVENTIONS IN INDIA AND
ABROAD ................................................................................................................................................................ 26
6. POTENTIAL STRATEGIES FOR URBAN ACSM .................................................................................... 33
REFERENCES ………………………………………………………………………………………………………………….37

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Barriers and Facilitators for Early TB Detection and Completion of Treatment in Urban India
Abbreviations
ACSM advocacy, communication, and social mobilization
AYUSH Ayurveda, Yoga, Unani, Sidda, and Homeopathy
BCC behavior change communication
CME continuing medical education
CTD Central TB Division
DCGI Drug Controller General of India
DMC Designated Microscopy Centre
DOTS directly observed treatment, short-course
DR-TB drug resistant tuberculosis
GDF Global Drug Facility
GFATM The Global Fund to Fight AIDS, Tuberculosis and Malaria
GPS global positioning system
HBC high-burden country
ICRC International Committee of Red Cross
IEC information, education, and communication
IHBP Improving Healthy Behaviors Program
IPC interpersonal communication
KAP knowledge, attitudes, and practices
LSHG local self-help group
MDR-TB multidrug resistant tuberculosis
NGO nongovernmental organization
NRHM National Rural Health Mission
NTP National Tuberculosis Programme
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Barriers and Facilitators for Early TB Detection and Completion of Treatment in Urban India
pHCP private health care provider
PDA personal digital assistant
PP private practitioner
PPM public-private mix
PSI Population Services International
REACH Resource Group for Education and Advocacy for Community Health
RMC RNTCP medical consultants
RNTCP Revised National Tuberculosis Control Programme
SMS short message service
TB tuberculosis
UHIN Uganda Health Information Network
USAID United States Agency for International Development
WHO World Health Organization
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Barriers and Facilitators for Early TB Detection and Completion of Treatment in Urban India
Executive Summary
Globally, the burden of TB is estimated to be the highest in India. Of the estimated global
annual incidence of 8.8 million TB cases in 2010, nearly 2.2 million cases were reported from
India (Kapoor et al., 2012). After the failure of the National Tuberculosis Programme (NTP), the
Government of India launched the Revised National Tuberculosis Control Programme (RNTCP)
in 1997. The RNTCP was based on the global directly observed treatment, short-course
(DOTS). By 2006, the whole (100 percent) Indian population was covered by the DOTS
program. However, while huge improvements have been made in cure rates, India is yet to reach
its goal of achieving 70 percent case detection and 85 percent cure rate.
The current study reviewed the barriers the Indian government faces in reaching its goal. The
barriers were looked at both from patients’ perspective as well as providers’ perspective. One
key reason for the high prevalence of TB is that patients delay in seeking care from a qualified
provider. This trend is largely due to poor awareness about TB and its symptoms among
patients. Stigma is the other important reason, particularly among married women who are
afraid of being abandoned by the spouse and in-laws. From the providers’ perspective,
mismanagement in case diagnosis is the main factor fuelling this epidemic in India.
Underutilization of sputum microscopy, overreliance on chest radiography, and use of
suboptimal diagnostics, such as serological tests, are among the main factors resulting in disease
mismanagement. With regards to treatment, lack of a uniform treatment regimen followed by
private providers and lack of patient-centered approaches that enhance accessibility and
acceptability of DOTS are causing hindrance.
This report systematically presents the findings of the literature review under two headings: 1)
barriers to early diagnosis of TB and 2) issues related to TB treatment and compliance. The
barriers to early diagnosis of TB are further divided into two sections: 1) patient and general
population’s perspective and 2) providers’ perspective. Similarly, issues related to TB treatment
and compliance are also discussed from patients’ as well as providers’ perspectives. Evidence
was also sought in the literature about new interventions to improve the current situation.
Towards the end of the report, the reviewers make the following recommendations for policy
advocacy and pilot experiments:
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Barriers and Facilitators for Early TB Detection and Completion of Treatment in Urban India
A. A comprehensive ACSM strategy, including multiple channels of communication, to
raise awareness levels in the general population and use of mid-media and interpersonal
communication (IPC) to increase institutional referral for early diagnosis and treatment of
suspected TB cases
B. Use of technology to improve referral linkages, tracking of patients for follow up, and
prevention of treatment lapses and drug resistance
C. Appropriate engagement of private practitioners (PPs) through an effective public-private
partnership approach
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Barriers and Facilitators for Early TB Detection and Completion of Treatment in Urban India
1. Introduction and Objectives
In 2010, globally there were 8.8 million (range, 8.5–9.2 million) incident cases of TB, 1.1
million (range, 0.9–1.2 million) deaths from TB among HIV-negative people, and 0.35 million
(range, 0.32–0.39 million) deaths from HIV-associated TB. India emerged as the country with
the highest TB burden, accounting for one fifth (21 percent) of the global incidence. The global
annual incidence estimate stood at 9.4 million cases, of which 2 million cases were estimated to
come from India. India ranked 17 among 22 high-burden countries (HBCs) in terms of TB
incidence rate. (Source: WHO global TB report, 2010).
Figure 1: TB incidence by country

Source: WHO Global TB report, 2010

The Government of India’s 12th five-year plan envisions a ‘TB-free’ India, with reduction in the
burden of disease until it is no longer a major public health problem. To achieve this vision, the
Revised National Tuberculosis Control Programme (RNTCP) has adopted ‘universal access’ as
its new objective to ensure quality diagnosis and treatment of all TB patients in the country. The
program plans to achieve this by deploying rapid diagnostics for TB and drug resistant TB (DR-
TB), expand services for management of multidrug resistant tuberculosis (MDR-TB), strengthen
urban TB control, bolster public-private mix (PPM) initiatives, improve the quality of basic
directly observed treatment, short-course (DOTS), and align the initiatives with the National
Rural Health Mission (NRHM) supervisory structure.
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Barriers and Facilitators for Early TB Detection and Completion of Treatment in Urban India
Objectives
The main objectives of the current situational analysis are to:
 Identify key issues related to TB control scenario in India
 Review existing interventions for TB control in India and globally
 Outline probable urban advocacy, communication, and social mobilization (ACSM)
strategies for TB
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